Dear Readers,

In this issue we will discuss a common, frustrating, but not particularly threatening condition – acne rosacea. Sometimes called “adult acne,” this idiopathic condition is usually benign but it has some complications that are worth noting. Imagine being a fair-skinned man in your 50s. You have noticed that over time, much of your face now appears to have become permanently reddened—like a sunburn that never fades. You outgrew adolescent acne 30 years ago, but now you see bumps and pimples over your cheeks and on your chin. Occasionally they sting or itch. Your nose has become enlarged and the skin has become thick and bumpy. Tiny red lines appear on your face: these are especially noticeable when you drink hot beverages or eat spicy foods. Worst of all, some friends and acquaintances assume that your skin is a sign of chronic alcohol abuse: you find yourself constantly defending yourself against that prejudgment. These are the signs and symptoms of acne rosacea.

What is acne rosacea?

Acne rosacea is a skin condition that affects mostly middle-aged, fair-skinned adults. It is most common among 30 to 60-year-olds. Although it is diagnosed in women slightly more often than in men, men tend to have it in a more severe form. Rosacea is very common; estimations suggest that about 14 million Americans may have it, although not always so severely that treatment is required.

Despite being common, acne rosacea remains mysterious. It runs in cycles of flare and remission, but does not appear to be auto-immune in nature. It can lead to the appearance of pustules that clear up with antibiotic use, but it is not a specific bacterial infection that can be cultured and identified. Some research points to two microbial infestations, but research on these factors remains inconsistent and inconclusive. Because the cause or causes of this condition remain elusive, its treatment is limited to addressing symptoms only. Acne rosacea is considered to be a manageable, but not curable, condition.

Symptoms of Acne Rosacea

Acne rosacea typically affects the skin of the face, focusing especially on the cheeks, forehead, and chin—often the places that acne vulgaris (“common” acne associated with the changes in testosterone secretion that occur during puberty) appears. Many people find that their skin becomes reddened and bumpy or even pimply, and may stay that way for weeks and months. Then, for no known reason, symptoms resolve and the skin goes back to normal for an undetermined period of time. Other people find that the changes are permanent and progressive. Acne rosacea usually spares the skin around the eyes, but one version can affect the conjunctiva and even lead to the risk of corneal damage.

Causes of Acne Rosacea

Causes of acne rosacea are mainly unknown. One of the frustrating things about this condition is that triggers may vary widely for people, and that the tissue changes seen in skin biopsies of people with this condition are inconsistent. Some of the features that occur often include:

• Vascular changes in the skin. The affected areas of skin appear to have more blood vessels than in unaffected skin, and these tiny arterioles, venules and capillaries are hyper-reactive to signals for dilation. This is what leads to the permanent tiny red lines or “spider veins”; the technical term is telangiectasias.
• Reactions to climate changes. Some people with acne rosacea find that their symptoms flare with UV radiation (i.e., sun exposure). Others find that moderate sun exposure helps to resolve symptoms. Many report that exposure to cold winds or rapid changes in humidity are triggers.
• Matrix degeneration. Irritating chemicals related to cellular injury can lead to long-term microscopic damage to the skin and superficial blood vessels. This can exacerbate and prolong the inflammatory response.
• Microbial infestation. Some patients with acne rosacea appear to have a higher-than-average population of common microscopic mites that colonize hair follicles. These patients sometimes have a positive reaction to the same treatment that is used for a different mite infestation called scabies. Other research points to the possibility of a skin infection with H. pylori bacteria, but this doesn’t address the fact that the vast majority of people exposed to this pathogen don’t develop acne rosacea.
• Medication and foods. Oral and topical steroid use appears to exacerbate symptoms for some patients, and many people find that hot beverages and spicy foods cause flushing and flares of their condition.

Types of Acne Rosacea

In 2004, a committee of specialists convened to compare notes and create some clear guidelines for subtypes of acne rosacea in an effort to create more awareness and to strategize the best treatment options for each type. The types of rosacea that they identified are:

• Type 1: Erythematotelangiectatic rosacea. This involves chronic flushing, red skin, and the development of tiny telangiectasias, aka spider veins.
• Type 2: Papulopustular rosacea. This type involves persistently red skin and transient bumps, pimples, and pustules.
• Type 3: Phymatous rosacea. This type involves permanently thickened, bumpy skin around the nose, called “rhinophyma.” Readers who remember the comedian W.C. Fields will recognize rhinophyma from his image.
• Type 4: Ocular rosacea. This is perhaps the most dangerous form of acne rosacea. It affects the eyes, beginning with conjunctivitis and frequent styes, but it can progress to cause scarring and permanent vision loss if it damages the cornea.

Treatment

This idiopathic disorder has no permanent cure, and so is treated palliatively. Patients are taught to recognize their specific triggers, and to avoid them when possible. Acne medication like Accutane is often prescribed. If mites are suspected, patients may be counseled to try the same skin cream recommended for scabies infestation. Photodynamic therapy (combining oral medication with careful doses of UV radiation) works for some patients. Laser surgery or dermabrasion may help the appearance of the skin and mask telangiectasias. Plastic surgery may be considered for a person with advanced rhinophyma. None of these interventions are considered to be a permanent solution for acne rosacea, however.

What about massage?

Specific massage promotes local blood flow as the skin warms and capillaries dilate in the area being addressed. For most clients this is a benefit, but for clients with acne rosacea facial massage could be a trigger for uncomfortable flushing and redness. As long as no infection is present, lymph drainage modaliies may help decrease fluid retention and any local edema. Therapists must be careful about using a lubricant that doesn’t irritate the skin or lead to a hyper-reaction.

Massage is unlikely to make any direct or specific changes to acne rosacea, but the chance to receive educated, non-judgmental touch may be an important positive factor in the life of someone who lives with this common and frustrating condition.

Well readers, do you have questions about medical issues that are presented in your contact with clients? Let me know – what’s on your table? Until then, many thanks and many blessings.

Resources

1. Alai NN. “Rosacea.” MedicineNet.com. http://www.medicinenet.com/rosacea/article.htm.
2. “All About Rosacea.” National Rosacea Society. http://www.rosacea.org/patients/allaboutrosacea.php.
3. Kupiec-Banasikowska A. “Rosacea.” Medscape. http://emedicine.medscape.com/article/1071429-overview.